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Student Leadership and Development
Membership Roster/Authorization for Release of Confidential Information
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Name of Organization:President Stan State Email:
Academic Chair Email:
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President Name:
Academic Chair Name:		President Phone Number:
Academic Chair Phone:
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INSTRUCTIONS:

1. Click FILE > MAKE A COPY. This will allow you to type on your own copy, not the template.
2. Rename YOUR COPY as "Organization_Semester_Year". EX: "SLD_Spring_2022"
3. List all active and new/prospective members. If a member has been inactive for a year or more, do not include them on your roster.
4. Share with the following email addresses: jdanaya@csustan.edu, stanstateorgadvisor@gmail.com, sldfslintern@csustan.edu, sldorgsintern@csustan.edu

By signing the form below you understand and agree to the following statement:
It is my understanding that the organization listed above will be requesting grade information from my academic record for scholarship purposes. I authorize Student Leadership & Development to release this information to the organization's President for this purpose. I further understand that this information will remain confidential and will be used for schoalrship and recognition purposes only.
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STATUS KEY
X= New Member A= Active Member I= Inactive G= Graduating this Semester A/G= Active and Graduating this semester
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NameStudent IDYear in School (FR, SO, JR, SR)
STATUS
(KEY ABOVE)		POSITIONSignatureDateFall 2022
G.P.A		Spring 2023
G.P.A
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